What is the role of vasopressors and inotropes in septic shock?

The current standard of care in septic shock involves the administration of empiric antibiotics, intravenous fluids, and, if unresponsive, vasopressor agents. Norepinephrine remains the vasopressor of choice. Phenylephrine is less effective and may be harmful. Dopamine and epinephrine are effective but often have unacceptable metabolic side effects. Vasopressin enhances the effectiveness of norepinephrine. There are no data to support the use of levosimendan, phosphodiesterase inhibitors or angiotensin II. Vasopressors can be delivered, relatively safely, through a peripheral cannula. It is likely that pressors will be used earlier in sepsis in the future, but clinicians must be aware of catecholamine overload syndrome. There are intriguing data that may support the concomitant use of norepinephrine and beta blockers.